Healthcare Provider Details

I. General information

NPI: 1407469455
Provider Name (Legal Business Name): TYLER JAMES BARRETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GRANT AVE
OMRO WI
54963-1398
US

IV. Provider business mailing address

487 SECURITY BLVD UNIT 16
HOWARD WI
54313-2703
US

V. Phone/Fax

Practice location:
  • Phone: 920-685-2755
  • Fax:
Mailing address:
  • Phone: 920-450-2890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2904
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: